The Minister for Housing and the Central

Government Sector

Mr S.A. Blok

PO Box 20011

NL-2500 EA THE HAGUE

Date: 15 January 2014 Appendices: 3

Reference: RLI-2014/27

Cc: M.J. van Rijn,

State Secretary for

Health,Welfare and Sport

Subject: Advisory letter: Living independently for longer – a shared responsibility of the housing,

health and welfare policy domains

This advisory letter has been produced in association with the Scientific Council for

Government Policy (WRR)

Dear Minister,

In your letter of 11 June 2013, you – in conjunction with the State Secretary for Health, Welfare and

Sport, Mr Van Rijn – request the Council for the Environment and Infrastructure (Rli) to advise you

about the implications of the proposed reforms of long-term care for the housing market, public

governance, and spatial patterns. You ask the Council to consider the relevant aspects in a broad

context.

The Council notes that the primary objective of the reforms, as set out in the Letter to Parliament

Van systemen naar mensen1 (From Systems to People), is to enable people to live independently for

longer, with appropriate care provided in the home setting (see Section 2.1). This aim is fully in

keeping with the autonomous societal development whereby people do indeed wish to live

independently and retain control of their own lives (see Section 1). The reforms seek to accelerate

the ongoing development of small-scale housing forms within the local community for people with a

disability or infirmity and to increase the provision of domiciliary care. The Council endorses the

decision to adopt this policy. In the Council’s view, the reforms will generally offer greater

opportunity, in both the short and longer terms, to promote social integration of people with a

disability or infirmity within their communities, to address the personal housing preferences of those

with a care requirement, and to encourage the market to develop new housing and service concepts.

In the short term, however, the Council foresees a number of difficulties further to the various policy

amendments (Section 2) and their implementation within the housing, health and welfare domains.

1 House of Representatives (2013), Beleidsdoelstellingen op het gebied van Volksgezondheid, Welzijn en Sport,

letter from the Minister and State Secretary of Health, Welfare and Sport to the House of Representatives, 8 February 2013, Proceedings 2012-2013, 32620, No. 78

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The Council identifies the following main issues.

There is a worsening shortfall in the availability of places within ‘assisted living’ concepts (which

vary in terms of the degree of medical or nursing care provided) for those with a disability or

infirmity (see Section 3.1). The demand-supply imbalance can be seen in both quantity and

quality. The proposed reforms provide for a process of ‘extramuralisation’. This means that, over

the next five years, an annual average of some ten thousand senior citizens, thirteen hundred

disabled persons, and eight hundred psychiatric patients under the care of the mental healthcare

services (GGZ departments) will become ineligible for residential care because they are assessed

as having a ‘lesser’ care requirement. There is no guarantee that these people’s current

accommodation or its setting (the neighbourhood) will permit the desired degree of

independence. It is the most vulnerable members of society who are likely to face the greatest

difficulty in the years to come as affordable alternatives to remaining in their own homes (with

appropriate care) are still few and far between.

The spatial requirements for the combination of housing, healthcare and welfare differ greatly

between and often within urban, suburban, and rural municipalities (see Section 3.2). It is

necessary to conduct a local inventory of both the accommodation requirement and that for

services and amenities on a regional basis, thereafter ‘zooming in’ to seek appropriate solutions

at the local level.

Under the current proposals, access to intramural care is to be restricted within a relatively short

time span. It will not be possible to create suitable alternatives within that period, even where

the buildings themselves are already in existence and require only modifications or a change of

designated usage. The Council has calculated that over four million square metres of existing

care sector real estate must be renovated or adapted (see Section 3.3). The organisations which

own and manage these buildings may decide to close them altogether, which will inevitably have

far-reaching consequences for residents and the local community. The demand for clustered

accommodation with (nursing) care will increase again in future due to population ageing. Given

more time, solutions other than closure can be explored, thus avoiding the write-off of valuable

capital assets.

The formation of coalitions should be encouraged, such as partnerships between housing

associations, healthcare institutions, and welfare service providers: the stakeholders responsible

for creating a link between the relevant policy areas for people in need of care. Given the

aforementioned autonomous societal development and the objectives of the reforms, this

approach would bring patient autonomy that much closer. However, the Council notes that the

formation of such coalitions is sometimes hampered by overly restrictive policy. The combination

of the proposed policy amendments (see Sections 2.1 and 2.2) and the uncertainty with regard

to the content of the resultant legislation is likely to prompt organisations such as housing

associations and healthcare institutions to focus on short-term survival and risk avoidance. They

may also opt to discontinue some activities, passing their tasks and responsibilities to others.

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Now more than ever there must be a long-term focus if the common objectives of the housing,

healthcare and welfare policy domains are to be achieved.

Creating the desired opportunities for the housing, healthcare and welfare domains entails a

complex investment strategy covering:

- The renovation and redesignation of existing care sector real estate

- The adaptation of existing dwellings to make them suitable for continued occupation by

people with a disability or infirmity

- The development of new assisted living concepts

- More effective use of technology (such as ‘domotics’)

- The maintenance or improvement of local amenities to enhance the quality of the residential

environment

- Innovation in care processes to enable tailor-made care, including the more intensive forms,

to be provided in the home

In short, there are obstacles to overcome and investments to be made. The current economic

climate and the nature of several policy amendments may discourage certain stakeholders from

making such investments. At the same time, regulators are focusing more closely on the

performance of a stakeholder’s primary, core tasks. This stands in the way of achieving optimum

synergy between the various stakeholders. That synergy is absolutely essential in the common

domain of housing, healthcare, and welfare. Some policy proposals prompt stakeholders to focus on

their own interests, while the short timeframe proposed for the implementation of the reforms is

forcing them to make short-term decisions which may well lead to the loss of valuable capital assets

in the longer term.

The Council views this situation as undesirable. Accordingly, we advise the government to formulate

a clear vision on housing, healthcare and welfare covering the next ten to fifteen years. This vision

should clearly state which chronic care indications are to be subject to the separation of housing and

care costs (see Section 3.1), as well as the route by which this separation will be sought. This

approach will create greater clarity for all stakeholders and will serve to alleviate current

uncertainties. The parties involved will then be able to develop a long-term strategy for their real

estate holdings as well as for housing in both the rental and owner-occupied sectors, whereupon

appropriate investments can be made.

To overcome the obstacles outlined above, the Council makes the following recommendations, which

are elaborated in Section 5.

Stakeholders should be given greater room to create synergy between the domains. Seeking

cooperation between the housing, healthcare and welfare sectors should be regarded as part of

all parties’ core task. This entails a further financial separation of housing and care costs,

together with a clearer correlation between the responsibilities of the Waarborgfonds Sociale

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Woningbouw (Social Housing Guarantee Fund; WSW) and those of the Waarborgfonds voor de

Zorgsector (Guarantee Fund for the Health Care Sector; WFZ).

Investment incentives should be created, including those encouraging stakeholders to invest in

joint objectives. ‘Split incentives’ should be removed, while the members of the target group

should be encouraged to devote timely thought to their desire to (continue) living independently

and the measures they must take to allow them to do so.

More time and greater flexibility should be allowed with regard to the transformation of care

sector real estate, to include allowing real estate owners to devise and implement a phased

transition plan which devotes due attention to the social-spatial context and the interests of the

more vulnerable members of society.

The remainder of this advisory letter considers the obstacles and the Council’s recommendations in

further detail.

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1. Autonomy and housing wishes

1.1 Independent living as the norm for people with (lesser) care requirements

The majority of people who require care or assistance wish to retain control of their own lives and

live as independently as possible2. This applies equally to seniors with restricted mobility, adults with

a physical or intellectual disability, and those under the care of the mental healthcare services3.

Individual freedom (of choice) is a fundamental human need, and one which is respected and

supported by government policy. Many people with a disability have already met that need: they live

independently, perhaps with medical care or domestic help, or in a protected or ‘sheltered’ setting.

Of all senior citizens with a care requirement, 74% live independently, as do 60% of persons with a

disability and 87% of those under the care of mental healthcare services4. The trend whereby people

who require care or assistance wish to retain personal control of as many aspects of their lives as

possible is expected to continue over the coming decades.

Government policy which seeks to facilitate independent living by those with a care requirement is

nothing new. In fact, only one decade (1963-75) saw a policy in which the construction of

retirement homes was actively promoted and efforts were made to encourage seniors to take up

residence. The government’s 1975 Second Policy Document on Care for the Elderly5 can be seen as

a milestone in that it expressly stated that everyone should be permitted to live independently for as

long as possible. ‘Deinstitutionalisation’ also became an important aim of care for persons with a

physical or intellectual disability as residential care gave way to the concept now widely known as

‘care in the community’.

The autonomous societal development and government policy have caused a significant change in

intramural capacity. In 1980, there were 150 thousand residential care places. By 2010, this figure

had fallen to 84 thousand despite a twofold increase in the number of people aged 80 or over in the

meantime (see Appendix 2, Table 2). Today, some 688 thousand people receive domiciliary care, of

whom 369 thousand require only general domestic assistance rather than any form of medical or

nursing care (Appendix 2, Table 3).

2 PBL Netherlands Environmental Assessment Agency (2013), Vergrijzing en woningmarkt, The Hague; Trimbos

Institute (2012), Trendrapportage GGZ 2012 - Deel 1: Organisatie, structuur en financiering – Ambulantisering, Utrecht; Netherlands Institute for Social Research (2005), Zorg voor verstandelijk gehandicapten, The Hague 3 This advisory letter is confined to the impact of the proposed reforms of long-term care on the housing market

for adult members of the target groups. 4 CBS/Statistics Netherlands (2013), Monitor Langdurige Zorg

(http://www.monitorlangdurigezorg.nl/kerncijfers/indicatie-gebruik/Paginas/default.aspx, retrieved 20 December 2013); Kwartel, A.J.J. van der (2013), Brancherapport gehandicaptenzorg 2012, Utrecht: Dutch Association of Healthcare Providers for People with Disabilities (VGN); Trimbos Institute (2012), Trendrapportage GGZ 2012 – Deel 1: Organisatie, structuur en financiering Ambulantisering, Utrecht 5 House of Representatives (1975), Nota bejaardenbeleid 1975, Proceedings 1974-1975, 13463, No. 2

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Between 1998 and 2008, the demand for care for persons with an intellectual disability grew by an

average of 9% per annum. Almost half of this increase was in the long-term intramural sector,

although demand for domiciliary care also showed a significant rise6. In the mental healthcare

sector, the number of clinical places fell to below twenty thousand in 2002 but has since shown

some increase. There has been extremely strong growth in assisted living and sheltered

accommodation concepts, from just over four thousand places in 1993 to approximately thirteen

thousand in 20097. In 2012, an administrative agreement was entered into by the government (the

Ministry of Health, Welfare and Sport), the mental healthcare providers, health insurance

companies, and patient organisations, whereby the current clinical capacity of the mental healthcare

sector will be reduced by a third by 2020 (compared to that in 2008).

1.2 Housing preferences and willingness to relocate

The majority of people who require care or assistance have the same housing wishes as anyone

else: they wish to be able to live independently in an affordable property of their own choosing, in a

pleasant neighbourhood with various amenities, and with a (diverse) social network8. Given the

choice, most do not wish to relocate to another area, since doing so would sever links with their

social network and severely disrupt the lives they have established9. Reluctance is even greater if

the proposed new home fails to meet their main wishes and requirements: the proximity of the

social network and the ability to receive appropriate care at home, with only a moderate increase (if

any) in monthly expenses. By way of illustration, 65 in every one thousand senior citizens (aged 65

and over) moved to new accommodation in 1995. By 2011, this figure had fallen to just 48. Over

two thirds of those who did relocate remained within the same municipality10. On top of that,

homeowners wishing to relocate must first (be able to) sell their property, which is often an

additional hurdle. The problem is at its most acute in areas which have a weaker housing market,

such as those with a decreasing population or which are less in demand due to social problems.

Properties which are poorly maintained or are not adequately insulated are also more difficult to sell.

A desire to live independently does not necessarily mean that the current home and its setting will

permit doing so. In many cases, (temporary) physical modifications are necessary to allow the

necessary care or assistance to be provided. Maintaining independence and autonomy may also

6 Ras, M., Woittiez, I., Kempen, H. van & Sadiraj, K. (2010), Steeds meer verstandelijk gehandicapten? Ontwikkelingen in vraag en gebruik van zorg voor verstandelijk gehandicapten 1998-2008, The Hague: Netherlands Institute for Social Research 7 Trimbos Institute (2012), Trendrapportage GGZ 2012 – Deel 1: Organisatie, structuur en financiering Ambulantisering, Utrecht 8 Netherlands Institute for Social Research (2004), Met zorg gekozen? Woonvoorkeuren en woningmarktgedrag van ouderen en mensen met lichamelijke beperkingen, The Hague: Ministry of Housing, Spatial Planning and the Environment (VROM); Kam, G. de, et al., (2012), Kwetsbaar en zelfstandig. Een onderzoek naar de effecten van woonservicegebieden voor ouderen, Nijmegen: Institute for Management Research 9

In its work programme for 2014, the Dutch Council for Public Health and Health Care (RVZ) announces the intention of exploring the possibilities and limits of the extramuralisation of care for persons with severe learning disabilities and patients with a chronic psychiatric condition. 10 Netherlands Environmental Assessment Agency (2013), Vergrijzing en woningmarkt, The Hague

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demand a relocation to alternative accommodation where such care is possible and where the

impact of any disability or infirmity is minimised.

The physical setting in which the home is located also does much to determine the level of

independence and satisfaction that can be achieved. Social isolation must be avoided. The

neighbourhood must therefore have an appropriate level of amenities (care, welfare, shops, and

activities). It must be accessible, safe, and have a reasonable level of social welfare. Within such a

vital setting, people with a disability or infirmity can not only live independently but can avoid social

isolation and loneliness. People who require care or assistance therefore make a balanced

consideration. Based on their wishes, preferences, and budget, they decide what will be the best

combination of accommodation, residential environment, care, amenities, and overall welfare. The

reforms in long-term care have prompted a societal discussion about the costs of housing and care,

and about who should be responsible for those costs. The Council sees a development whereby a

greater proportion of the total costs is apportioned to the housing domain; they are deemed

‘accommodation costs’, for which the individual is responsible. The costs of care, which are covered

by health insurance and are therefore collectively funded, form an ever smaller proportion of the

total.

2. Relevant policy amendments affecting housing, healthcare, and

welfare

2.1 Reforms of long-term care: four main shifts

The reforms of long-term care place a focus on four shifts:

- Encouragement of independent living with care provided in the home (extramuralisation)

- More management responsibility to be devolved from central government to local authorities

and health insurers

- No rise in collective costs despite greater demand for care (higher personal contributions)

- Less formal care (and hence more informal care)

As part of the reforms, access to intramural care is to be restricted for people with a lesser care

requirement. In 2012, approximately 263 thousand people were referred to intramural care services

further to the provisions of the Algemene Wet Bijzondere Ziektekosten (General Exceptional Medical

Expenses Act, AWBZ). This figure has remained relatively constant for the past several years. The

Ministry of Health, Welfare and Sport (VWS) expects the reforms to reduce the number qualifying

for intramural care by approximately 78 thousand, being those with a lesser ‘care indication’ (see

Table 4 in Appendix 2). This means that intramural facilities for the elderly, people with physical and

intellectual disabilities, and psychiatric patients will see a 30% fall in patient numbers (Table 1). This

represents a significant decrease in the required capacity, even allowing for the fact that the

demand for places in nursing homes for seniors is likely to fall even without the proposed policy

amendment due to the preference for independent living.

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Table 1: Projected number of people ‘living independently for longer’ according to the

scenario presented in the Letter to Parliament on the reform of long-term care

Indications which no longer qualify for

intramural care

Absolute

number of

patients

Percentage of total

intramural care

capacity

All VV1, VV2 and VV3 indications; 50% of VV4 57,700 38%

All VG1 and VG2 indications; 50% of VG3

All LG1, LG2 and LG3 indications

All ZG1 indications

15,100 19%

All GGZ1 and GGZ2 indications 5,100 18%

Total 77,900 30%

Source: House of Representatives (2013), Hervorming van langdurige ondersteuning en zorg, appendix to Letter to Parliament Hervorming langdurige zorg: naar een waardevolle toekomst, submitted to the House on 25 April 2013, Proceedings 2012-2013, 30 597, No. 296

Key: The ‘indication’ is a coding which represents the medical assessment of a patient’s care requirement. The letters refer to the nature of the disability or infirmity, the figures to its severity. GGZ = Psychiatric condition (often acquired, e.g. depression, addiction etc.) LG = Physical disability VG = Intellectual disability (learning difficulties, usually congenital) VV = Nursing and care (e.g. age-related infirmity) ZG = Sensory impairment (visual and auditory disability)

2.2 Other relevant policy amendments

This section briefly discusses other policy amendments insofar as they are relevant to the broader

context of independent living and autonomy.

Separation of housing and care

By implementing a financial separation between housing and care, the government wishes to reduce

the impact of accommodation costs on the collective care budget. Housing costs are an individual

responsibility, while care is funded separately as a combination of collective and private

responsibility. This separation will create greater transparency with regard to the relationship

between the two types of cost. The financial separation is currently being implemented with regard

to the lesser care requirement indications. The Ministry of VWS’s briefing document of 1 June 2011

on long-term care states the intention of extending it to cover more intensive care indications by

means of a phased process.

Normative Accommodation Component

The ‘Normative Accommodation Component’ (NHC) is being phased in as a means of establishing

the amount of funding per intramural place. This process will be completed in 2017. The NHC is

directly linked to the actual number of patients that an institution has at any one time rather than its

total capacity. Unfilled capacity will therefore result in reduced income whereas previously, capital

investments made were entirely reimbursed on the basis of post-calculation. The amount paid in

respect of capital expenditure also took into account investments in communal areas, fire safety,

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accessibility, and the care infrastructure. From 2018 onwards, healthcare organisations will bear the

full risk of any unused capacity. If property currently used for intramural care is rented out on the

rental market (perhaps as accommodation for independent or assisted living) in order to reduce the

vacancy rate, it will be difficult to determine a rental price which will adequately recoup the capital

investments (see Section 3.3).

Services of General Economic Interest

Towards the end of 2011, the European Commission adopted new regulations which apply to so-

called ‘Services of General Economic Interest’ (SGEI)11. These regulations establish the conditions

under which state aid may be provided, such as a loan guarantee on behalf of a housing association.

One condition is that the association must allocate at least 90% of its social housing rental stock to

households with a taxable income of less than EUR 34,678 per annum (the Dutch House of

Representatives has recently passed a motion setting the upper income threshold for rented social

housing at EUR 38,000). When making an SGEI investment, housing associations are able to call on

a guarantee fund – the Waarborgfonds Sociale Woningbouw (WSW) – which enables them to obtain

finance from commercial lenders at favourable rates of interest. Investments in activities other than

‘Services of General Economic Interest’ are not eligible for this guarantee. Housing associations can

opt to apply either a legal or an administrative distinction between their SGEI and non-SGEI

activities. An administrative distinction will entail closer supervision by the regulatory authorities,

whereby associations will be permitted fewer non-SGEI activities even if they are of service to their

core task.

Landlord levy

Landlords who rent more than ten properties in the social housing sector must pay a levy calculated

according to the total value of their real estate holdings. This levy is expected to generate over 1.1

billion euros in state revenue in 2014, rising to approximately 1.7 billion in 2017. However, it also

decreases housing associations’ investment ability, and hence the part they can play in pursuing the

common objectives of housing, healthcare and welfare policy.

Decentralisation to local authorities

Many areas of government responsibility are now being decentralised to local authority level: Youth

Health and Welfare, the Participation Act, and the Planning and Environment Act, while some

provisions of the General Exceptional Medical Expenses Act (AWBZ) are to be transferred to local

authority responsibility as part of the Wet maatschappelijke ondersteuning (Social Support Act;

WMO). It now falls to local authorities to assume a managerial role and to develop the necessary

expertise, allowing for the uncertainty of future developments and diminishing budgets in these

times of austerity.

11 Services of General Economic Interest are services related to public interests in quality, accessibility and

security of supply for large groups of citizens.

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3. Consequences for the housing market and spatial patterns

3.1 Can the housing market accommodate the trend towards more autonomy?

Greater demand for sheltered accommodation and assisted living

The number of senior citizens in society is increasing, in both absolute and relative terms. In 2012,

there were 2.7 million people aged 65 and over living in the Netherlands, representing 16% of the

total population. By 2040, the number will have risen to 4.7 million (26%). The greatest increase

will be seen in the group aged 80 and over, who will represent 44% of the population over 65 by

205012. Changes will also be seen in terms of household composition, with increases in both dual-

occupancy and single-occupancy households. By 2030, there will be some 1.4 million senior citizens

living alone, compared with the current figure of 900 thousand13.

Among seniors who are no longer eligible for intramural care, it is estimated that 80% will still opt to

move into alternative accommodation as a result of their care requirement14. It is not clear what this

number is for people with a disability or under the care of mental healthcare services.

Extramuralisation therefore appears to have only a limited effect in terms of housing market

through-flow. The number of relocations will decrease by no more than 22 thousand15 in a six-year

period compared to the current situation of 450 thousand ‘movements’ (changes of occupancy) each

year in a total market of 7.26 million properties. However, the housing market itself has changed.

Throughout the 1990s and the early 2000s, it was buoyant and dynamic, with rising prices and a

high number of transactions. Today’s market is more static, with lower prices and fewer relocations.

In this type of market, every relocation can have a significant effect in setting off a chain of further

relocations, whereupon the impact of the extramuralisation policy will be that much greater.

The demand for ‘assisted living’ continues to rise. Assisted living means that (medical) care and

general help are available close at hand. Demand is already greater than supply, with a lasting

shortfall of over 40 thousand units (30% of the 2012 stock level). The extramuralisation of the ‘care

and nursing’ segment will serve to increase the shortfall by over 41 thousand units between 2013

and 2021, reaching a total of 81 thousand. Demand for ‘accommodation with services’ (a private

room or rooms in a managed complex which offers additional services such as meals and communal

areas) also outstrips supply, with a current shortfall of over 46 thousand places, or 26%16. As shown

in Table 5 in Appendix 2, there is also a growing shortage in the category ‘Seniors accommodation –

other’, which refers to units which are specifically designated for occupancy by seniors but which do

12 Huisman, C., Jong, A. de, Duin, C. van, Stoeldraijer, L. (2013), Regionale prognose 2013-2040. The Hague:

PBL Netherlands Environmental Assessment Agency and Statistics Netherlands 13 Campen, C. van (2011), Kwetsbaar alleen, The Hague: Netherlands Institute for Social Research 14 Galen, J. van, Willems, J. & Poulus, C. (2013), Monitor investeren voor de toekomst 2012, Delft: ABF Research 15 See Table 4 in Appendix 2. We base this projection on a maximum of 6,500 disabled persons, plus a maximum

of 4,600 mental healthcare services patients, plus 11,100 seniors (20% of 55,700). 16 Galen, J. van, Willems, J. & Poulus, C. (2013), Monitor investeren voor de toekomst 2012, Delft: ABF Research

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not provide any additional care or services. These are, for example, apartment buildings which apply

a minimum age of 55. The shortage of units in this category reached 63 thousand (31%) in 2012.

The increase in demand for all three types of accommodation is primarily due to the demographic

trend of population ageing.

The shortages are largely of a qualitative nature. Many units within the current stock – both rental

and owner-occupied – require modifications if they are to remain suitable for (continued) occupancy

by persons with a disability or infirmity. The Council expects housing requirements and preferences

to become even more diverse in future, and the senior citizen target group is no exception.

Moreover, a greater number of people with some care requirement (such as people with a physical

or intellectual handicap and psychiatric patients) will seek an appropriate home on the regular,

‘mainstream’ market. Accordingly, a much more diverse range of housing concepts must be made

available, to include individual and clustered units, with rooms of varying sizes depending on tastes

and intended usage, concepts which allow residents to determine the degree of assistance and

support they require, the use of ‘domotics’, and a choice between the urban environment and a rural

or semi-rural setting. Greater diversity will be made possible, in part, by the increased transparency

of housing and care costs. Their separation will enhance the individual’s freedom of choice based on

the price-quality ratio represented by the various forms of housing-and-care concepts. To ensure a

better match between the facilities available and the requirements of the target groups, the Council

considers it essential that the costs of accommodation and those of care are charged separately in

the intramural care sector as well. The current arrangements give rise to uniformity of

accommodation, thus limiting freedom of choice. Separation of costs will also create more

opportunities for civil initiatives and for innovation by the private sector. For this reason, the Council

is in favour of introducing the further separation of accommodation and care costs for all chronic

care indications, as previously endorsed by the Council for Public Health and Health Care (RVZ)17

and the Social and Economic Council of the Netherlands (SER)18 . To this end, the government must

formulate a clear vision for the coming ten to fifteen years, clearly stating the chronic care

indications to which the separation of accommodation and care costs is to apply and the manner in

which this separation is to be introduced.

A vital setting is of great importance

As stated in Section 1.2, the residential environment is every bit as important as the dwelling itself

in terms of independent and autonomous living. However, a vital setting may not be permanent: a

retirement home might close, for example. Indeed, the first planned closures have already attracted

some media attention. Retirement homes also play an important role in providing care and welfare

for local residents, so closure would mean the discontinuation of such services. It also means the

departure of the residents themselves who form the customer base for local shops and businesses

17 Netherlands Council for Health and Health Care (2005), Mensen met een beperking in Nederland. De AWBZ in

perspectief, Zoetermeer 18 Social and Economic Council of the Netherlands (2012), Naar een kwalitatief goede, toegankelijke en

betaalbare zorg, The Hague

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and who are often mainstays of local community activities. In short, the closure of a retirement

home affects not only its residents but the entire neighbourhood and its community.

Ideally, first-line healthcare centres and those which integrate some second-line (specialist)

expertise should be located in areas which have a more senior population. People who require care

can then continue to live in their own familiar surroundings, something they often attach great

importance to (see Section 1.2). Research confirms that seniors who have access to a full range of

services are able to live independently for longer than those in purely residential areas19. The

‘targeted neighbourhood approach’ – in which district nurses are on hand, there is an organised care

structure (known as ‘Buurtzorg’20), and effective use of IT resources – can also do much to facilitate

independent living. A suitable home in a suitable setting is a ‘prevention instrument’, serving to

reduce the demand for more intensive healthcare services.

The current stagnation on the housing market makes it more difficult for people who require care or

assistance to relocate, and for housing associations to offer suitable alternative accommodation.

Those units which do become available are often not the most desirable in terms of quality and

location. The ‘liveability’ of a neighbourhood can be a very important factor in allowing certain

members of the target groups, such as people with a physical or intellectual disability or psychiatric

patients, to live independently. If their financial resources are limited, they are forced to seek low-

rent accommodation, in which case they might be likely to find themselves living in areas in which

safety and social issues are a concern.

3.2 Spatial patterns: a very diverse picture

In the shorter term, it is the urban areas which will see the greatest growth in the number of senior

citizens in absolute terms, simply because the towns and cities have the highest population density.

In relative terms, however, it is the rural areas in which population ageing has the most marked

effect. The difference between the urban and rural areas will remain visible for many years to

come21. At the regional level, it is the Randstad conurbation, Flevoland, the eastern region of Noord-

Brabant, and West-Friesland which will see the greatest rise in the percentage of seniors (aged 65

and over)22.

In the rural regions, it is not always practicable or economically viable to maintain a full range of

social amenities and services in smaller residential areas. On top of that, in areas with a rapidly

19 Kam, G. de, et al. (2012), Kwetsbaar en zelfstandig. Een onderzoek naar de effecten van woonservicegebieden

voor ouderen, Nijmegen: Institute for Management Research 20 www.buurtzorgnederland.com 21 PBL Netherlands Environmental Assessment Agency (2013), Vergrijzing en Ruimte. Gevolgen voor de

woningmarkt, vrijetijdsbesteding, mobiliteit en regionale economie, The Hague 22 CBS/Statistics Netherlands (2012), Gemeenten zien aantal 65-plussers tot 2040 toenemen, article published

26 July 2012 (retrieved 20 December 2013 from http://www.cbs.nl/nl-NL/menu/themas/dossiers/vergrijzing/publicaties/artikelen/archief/2012/2012-bt-iag-65-plussers.htm)

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ageing population the number of younger people (of working age) able to provide those services is

dwindling21. One response to this situation is investment in technological and organisational

solutions, such as e-health resources, domotics, care cooperatives, and home deliveries from

(online) shops. This will enable people who require care or assistance to live (more) independently

even in the smaller residential districts23. The Council also anticipates the emergence of civil

initiatives in the form of cooperatives which establish small-scale housing concepts and care facilities

in villages. It nevertheless remains essential to devote attention to regional public amenities, such

as hospitals, libraries, and welfare centres. The current trend of scale expansion places accessibility

at risk, not least because the mobility of the target group is declining21.

It seems unlikely that we shall see any marked and deliberate spatial concentration of senior

populations on a par with the large-scale ‘retirement communities’ of Florida and elsewhere.

However, autonomous developments (especially where districts already have less diversity in age

cohorts) may result in some concentration of senior populations at a lower level of scale: the

retirement complex or seniors’ apartment building. Some concentration may also result from a

desire to live together on the part of a group of people requiring care or assistance, or on the part of

their (informal) carers. This desire may be prompted by feelings of loneliness or a lack of safety, the

wish to have “our sort of people” nearby, or to be close to carers. Where a number of (informal)

carers and volunteers come together to provide assistance to a group of people with care

requirements, a wider range of private housing-and-care concepts is likely to develop.

In the end, there will not only be marked differences between the urban, suburban and rural

environments, but also within one and the same setting, even extending to individual

neighbourhoods or residential districts. A local inventory of peoples’ housing requirements and

preferences is therefore required. Regional coordination is desirable because most housing

associations and care organisations are themselves organised on a regional basis, and because

people considering relocation usually search for suitable accommodation within a region. Moreover,

some amenities demand a regional level of scale in order to be economically viable.

3.3 Greater financial risks for the owners of care sector real estate

The developments on the property market and the policy amendments (see Section 2) place the

equity position of owners of care-related real estate under pressure and increase the financial risks

they face. Two thirds of care sector real estate is in the ownership of care providers, the remaining

third is owned by housing associations24. The extramuralisation of senior care will have the greatest

impact on the retirement and nursing homes. Housing associations own and manage over 50,000

23 Mulder, H. (2013), Meta-analyse Zorg op afstand, Utrecht: In voor zorg! 24 House of Representatives (2012), Scheiden van wonen en zorg (SWZ), technical briefing by the Ministry of

VWS of 7 March 2012, appended to Antwoorden op vragen Leijten over een technische briefing over het scheiden

van wonen en zorg in de AWBZ, Proceedings 2011-2012, No. 2012Z06716

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places within retirement homes: half the total number25. In broad terms, the owners of real estate

designed and structured to provide care to people with lesser care indications face three types of

risk:

Operational risks will be exacerbated by the decreasing (certainty of) revenues (see Table 6 in

Appendix 2) in the years to come which results from the extramuralisation policy and the

adoption of the NHC.

Book value (equity) risks will increase due to the decreased certainty of (rental) revenues,

causing the book value of real estate as a capital asset to fall.

(Re-)financing risks will be greater due to the decreasing certainty of revenues. Financiers

(banks and investors) and guarantors (local authorities, the WSW, and the WFZ) will adjust the

costs of (re-)financing accordingly.

The nature and level of risk may vary according to the type of owner. The interests of the

stakeholders, which should be mutually reinforcing, may actually be conflicting. For example, a care

provider concerned with short-term survival may opt to close the locations rented from a housing

association, continuing operations only in those locations it owns outright. From the broader social

perspective, this may not be ideal. The risks for housing associations which have a large number of

retirement homes in their portfolio become that much greater, whereupon their investment capacity

comes under even greater pressure.

Greater flexibility in care sector real estate is required, whereby one and the same location can be

made suitable to accommodate members of various target groups, with multiple functions under the

same roof. In order to reduce risks or avoid high vacancy rates, owners of care-related real estate

have the following options.

Offering the more intensive forms of care provision

The number of places in regular retirement homes rose from 46 thousand in 1980 to 74 thousand in

2010 (see Table 2 in Appendix 2). The average duration of occupancy is less than one year. The

number of places required will continue to rise due to population ageing26. However, ‘converting’

retirement home places to nursing home places requires permission from the regional care office.

Direct rental of (independent living) apartments in combination with domiciliary care services

This option is in keeping with the demand for more ‘assisted living’ and ‘accommodation with

services’ provisions. The care provider must then be prepared to act as the managing agent of the

relevant accommodation units, or to join forces with a housing association or private landlord. In the

case of smaller units, it may be desirable to set a rent which is below the current threshold for social

housing (i.e. EUR 699 per month) to ensure that these units remain affordable for those on lower

incomes. However, if the service surcharge permitted by law is applied in full (35% of the basic

25 ING Bank (2013), Themavisie Scheiden wonen zorg in de AWBZ: Deel II – Woningcorporaties 26 ING Bank (2013), Themavisie Scheiden wonen zorg in de AWBZ: Deel 1 – Ouderenzorginstellingen

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rent), it will often be impossible to apply a total rental charge below the threshold. Even in the case

of more expensive ‘free sector’ rental accommodation, the service surcharge could price units out of

the market altogether. This means that it will be difficult or impossible to derive a rental income

from existing care sector real estate, built under past legislation, which is sufficient to recoup the

capital investments. Moreover, depending on the age of the real estate in question, renovation may

be necessary in order to meet the quality requirements of prospective tenants.

Renting to other groups

Renting the property to groups other than those requiring care or assistance – such as students,

starters, or higher-income households – entails an entirely different role for healthcare providers. It

is a role more suited to housing associations and private landlords. The location, layout, and

condition of the building will determine whether rental to other target groups is possible. Not every

area has a student population, while people with higher incomes are likely to impose higher

requirements in terms of quality and comfort.

Disposal or demolition

In view of the impending overcapacity of regular retirement home places, the sometimes limited

options for a (quick) redesignation of purpose, or simply due to the age of buildings, it may be

necessary to sell or demolish care sector real estate. The Council is concerned by indications that

some care providers are already disposing of their real estate with some degree of haste, based on a

short-term strategy intended to serve their own immediate interests. While immediate closure of a

care location in order to ‘balance the books’ may be the cheapest option for the organisation

concerned, it may well prove a particularly expensive approach when viewed in the broader societal

perspective. The sale of a care sector building and/or land must be approved by an official

regulatory body, the College Sanering Zorginstellingen (CSZ). If permission for sale is conditional on

a higher market price, the property will not be of interest to non-commercial buyers such as housing

associations, since they will be unwilling or unable to make the additional investments required to

develop some alternative social function.

The short time span in which the government wishes to implement the extramuralisation policy

increases the likelihood of closures. A more gradual process would allow greater opportunity to

make appropriate modifications to care sector real estate. The Council has calculated that the

retirement homes, facilities for disabled care, and mental healthcare institutions which require

renovation or change of usage have a total floorspace of over four million square metres27. The

vacancy rate in other non-residential property is already extremely high: office space totalling over

seven million square metres is currently standing empty, as are many retail premises. The

introduction of care sector real estate onto this saturated market can only worsen the situation.

Compared to much of the property on the market, however, the prime location of many care sector

buildings makes them a more attractive proposition for conversion. If their owners were to opt for

27 TNO 2009, Investeringskosten per ZZP, basis voor een NHC voor de Care, Utrecht. This calculation is based on

77,900 intramural care places (see Table 1), each assumed to be 60 m2, giving a total of over 4.5 million m2.

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immediate closure and sale, it would have a major impact on both residents and the local

community. Within a few years, however, it is possible that demand for residential care will recover

due to population ageing. More time to consider options other than closure may reveal alternative

solutions and will avoid the write-off of valuable capital assets. Given the longer average occupancy

of their residents, facilities for disabled care have somewhat longer to adapt their property than

those facilities which cater to seniors. For mental healthcare institutions, the reduction in the

number of care places will mainly affect the ‘lighter’ forms of sheltered accommodation at the so-

called RIBWs (regional institutes for sheltered accommodation). In addition, restricting the duration

of admission to in-patient institutions will reduce the number of places required in the mental

healthcare segment.

4. A complex challenge for all stakeholders: synergy is required

4.1 Complex investment requirement

In the Council’s opinion, the desired changes in the domains of housing, care and welfare will

require not only an effective real estate strategy, as outlined above, but also a complex investment

programme covering:

- The adaptation of existing accommodation to render it suitable for people with a disability or

infirmity

- The development of new housing-and-care concepts

- More effective use of technology to support independent living

- The maintenance or improvement of local amenities to enhance the ‘liveability’ of the

neighbourhood

- Innovation in care processes to enable tailor-made care (including the more intensive forms)

to be provided in the home setting

It is not possible to quantify the investment requirement precisely. In broad terms, the amount

concerned will depend on factors such as: a) the level of comfort expected or demanded by

prospective residents and the degree to which they are willing to pay for adaptations, facilities, and

services; b) the vision of care providers with regard to the modification of amenities required to

facilitate appropriate care; c) the balance between accessibility and affordability when considering

the required level of scale; and: d) legislative requirements, such as those covering fire safety and

accessibility.

Adapting existing accommodation for use by people with a disability or infirmity

Most of the Netherlands’ housing stock is owner-occupied. Individual homeowners must take timely

action to ensure that their property remains suitable for occupation should they become less mobile

in future. However, not all homeowners are willing or able to make the necessary investments, and

the level of investment can vary greatly depending on the nature of both the home itself and the

required modifications. A new, higher lavatory would cost approximately three hundred euros, while

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a monitoring and ‘panic button’ alarm system might cost a few thousand euros. More extensive

structural modifications, such as widening doorways or enlarging a bathroom to provide wheelchair

access, could cost as much as fifty thousand euros. Many homeowners’ capital is tied up in the

property itself, whereupon it is desirable for banks to devise some arrangement whereby equity can

be released to finance this type of modification, for instance by remortgaging. A think-tank – the

Taskforce Verzilveren – has made a number of recommendations in this regard28.

There are also circumstances in which rented accommodation must be adapted. Responsibility is

shared by the tenant, landlord, and local authority (social services department). Minor modifications

can be made by the tenants themselves. In consultation with their housing association or landlord,

more extensive modifications may be implemented, whereupon any investment could be

compensated by means of a rent adjustment. Where modifications which the tenant simply cannot

afford are required, a subsidy application can be made to the local authority under the provisions of

the Social Support Act (WMO). Some local authorities have already entered into agreements with

housing associations under the WMO, setting out the modifications which are possible and

permissible, and who is responsible for their costs. Such agreements reduce the time that tenants

have to wait for a decision and ensure more efficient use of the available budget.

Development of new housing-and-care concepts

Demand for housing-and-care concepts is becoming ever more diverse29, which means that the

supply must also be diversified. There are many examples of innovation. The established providers

are already developing new concepts. Housing associations, for example, have introduced ‘kangaroo

homes’ (two independent but interconnected units) and temporary units which can be erected in a

garden in order to enable friends or family member to act as informal carers. Housing associations

are also involved in various third-party initiatives, such as projects launched by the parents of

children with a disability who wish to establish their own communal home, or initiatives devised by

Stichting Thuis in Welzijn, a foundation which is working to create small-scale accommodation for

single seniors, some of whom may have dementia. There are also several groups who are meeting

their own housing-and-care requirements by joining forces to contract the necessary services

directly. Similarly, several private sector organisations are now offering new housing-and-care

concepts or new forms of service provision. The logistics company TNT not only delivers products

but will assemble and install them as required. Some supermarkets have introduced a door-to-door

taxi service for their less mobile customers.

Alongside the new accommodation concepts, new forms of care provision are both possible and

desirable. Various care cooperatives have now been established, primarily in the rural areas. They

contract professional care services and coordinate the volunteers who provide care and

companionship to local residents in need. This enables people with a disability or infirmity to

28 Taskforce Verzilveren (2013), Eigen haard is zilver waard 29 Castelijns, E., Kollenburg, A. van, Meerman, W. te (2013), De vergrijzing voorbij, Utrecht: Berenschot

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continue living in their familiar surroundings, even in the smaller residential cores. The ‘Personal

Care Budget’ system also offers many opportunities to organise care provision differently. One

example is the ‘Thomas Houses’ project: small scale accommodation for groups of six to eight

people with an intellectual disability, with constant supervision by two resident carers.

More effective use of technology

A meta-analysis of seventeen pilot projects concludes that technology such as remote monitoring

systems will make long-term care more ‘future-proof’. The use of ‘domotics’ and effective follow-up

of any unusual situation reported by the automated sensors can enable people with a care

requirement to live independently in their own homes for longer. According to the meta-analysis,

this type of technology reduces the workload of care professionals by as much as 20%30. Both

carers and clients report a higher degree of satisfaction. Nevertheless, other pilot projects have

raised some concerns: expectations are too high, projects are slow to come off the ground unless

incentive subsidies are available, and the technology bears little or no relation to the organisations’

standard care processes31. It is difficult to establish a firm business case, while care professionals

may be reluctant to adopt the new technology. In some instances, the individual user is overlooked.

This suggests a ‘technology push’ rather than a desire to meet actual needs. It is important to

ensure that the technology is user-friendly, and equally important to consult and involve the end

user in its implementation.

Assuming that (informal) carers and patients will gradually become more au fait with technology,

the demand for technological aids can only increase. The urgency of introducing new technology will

become more acute in the years ahead, not least because local authority budgets will come under

even greater strain. The demand for care will rise while the number of staff able to provide that care

will fall. This means that – policy amendments and the resultant budget reductions notwithstanding

– there must be adequate incentives for the further implementation of technological solutions. In the

longer term, innovations such as care robots, driverless cars, gaming technology, and

exoskeletons32 will all play a part in increasing people’s autonomy.

Maintaining or improving local amenities in order to maintain or enhance the ‘liveability’ of the

residential environment

Amenities such as shops, transport services, daycare activities and care centres are not always

available or not always located where they are needed most. Moreover, the desired location for such

amenities can change over time. Local authorities must plan ahead to ensure that proper amenities

are indeed in the right place at the right time. In doing so, they must be aware that population

30 Mulder, H., (2013), Meta-analyse Zorg op afstand, Utrecht: In voor zorg! 31 Zorg voor de Toekomst Noord- en Oost-Groningen (2013), Zorg dichtbij. Resultaten van de actielijn zorg

dichtbij in een notendop 32

An exoskeleton is an external frame or ‘wearable robot’, with motorised segments corresponding to the limbs

and joints of the human body, providing assistance in mobility or rehabilitation.

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ageing can ‘shift’ from one district to another. Today’s new housing developments have a high

concentration of young families. In forty or fifty years’ time, such areas are likely to have a high

concentration of elderly residents. By the same token, today’s ‘ageing’ neighbourhoods may

eventually have a much younger population.

Innovation in care processes to make tailor-made care (including the more intensive forms) possible

in the home setting

If appropriate care is to be provided in the home, existing care processes must be modified and

updated. This demands a ‘cultural shift’ within the long-term care sector, whereupon the focus is no

longer on the system but on people, their possibilities, and their restrictions. Wherever possible,

care should be organised around the lives of the care recipients rather than expecting them to

organise their lives around care.

4.2 Roles and responsibilities

As noted above, investments must be made by homeowners, landlords, housing associations, civil

initiatives, healthcare organisations, welfare departments, project developers, health insurers,

private sector organisations, local authorities, and the government. Coalitions between these

parties, bringing together the domains of housing, care and welfare for the benefit of the target

groups, will help to achieve the desired situation sooner. There is, after all, a shared and integrated

objective. All three domains are important in enabling people to live independently and

autonomously for longer despite disability or infirmity. Research shows that a sense of ‘well-being’,

which extends beyond physical health to include mental and social aspects, reduces the demand for

care. However, the Council notes that the formation of such coalitions is being hampered by overly

restrictive policy. A combination of factors has prompted many stakeholder organisations to focus on

short-term survival, risk avoidance, and divestment of tasks. In this context, we can cite the

autonomous social development of wishing to live independently for as long as possible, policy

amendments such as the introduction of the ‘landlord levy’ and the NHC (see Section 2.2), stricter

regulation of the primary tasks, decentralisation, as well as uncertainty with regard to the form and

content of future legislation as a result of those policy amendments. A longer-term focus is essential

if the common objectives of the housing, healthcare and welfare domains are to be achieved.

In the Council’s opinion, deferring investments until the economy has recovered would be

imprudent. Rather, the Council sees opportunities in allowing people with a care requirement, as

well as creative private sector parties, to assume a more prominent role in addressing the joint

objectives. If they are allowed to develop their ideas, it will be possible to achieve a closer match

between the care requirements and the new ‘smart’ provisions which will emerge. Stakeholders such

as housing associations, healthcare providers and health insurers should be encouraged to

contribute to this process and to cooperate with each other in the interests of synergy. We must find

a good ‘mix’ which mobilises the investment capacity of individual residents, private sector

organisations, care providers, housing associations and other landlords, and government itself. By

adopting a broader framework in which all interests are taken into account, the various stakeholders

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will be able to arrive at a long-term strategy based on people’s actual requirements and their

possibilities.

5. Recommendations: room for cooperation; incentives; flexibility and

time

The transformation of housing-and-care provision is one of the major social issues of today. As in

other domains (economic, social, and ecological), a quest for new standards and for new social and

economic values has begun. New definitions are being sought for concepts such as ‘earnings and

payback models’, ‘sustainability’, ‘equality’, and ‘governance responsibility’. As this quest continues,

there may be occasions on which the traditional arrangements are at odds with the new, as yet

incomplete arrangements. The various stakeholders must grow into their new roles. The

government’s role will be far less prominent: rather than controlling the entire process in a ‘top-

down’ manner, it will become more of a facilitator.

According to the level of scale, the tasks and challenges for districts, municipalities, regions, and

provinces will differ. Bespoke, ‘tailor-made’ solutions are required at each level. It will only be

possible to arrive at such solutions if the overall objective is fully clear to all stakeholders, who must

consistently act in a way which addresses the common interests. This demands greater opportunity

for cooperation (Section 5.1), investment incentives (Section 5.2), as well as flexibility and time in

which to bring the transition to a successful and measured conclusion (Section 5.3). The Council has

formulated recommendations in each of these three areas, and has incorporated those

recommendations into the stakeholder agendas presented in Appendix 1.

5.1 Create room for cooperation

1. Regard cooperation between the stakeholders as part of their core task

In principle, it is appropriate for stakeholders – whether private or public – to concentrate on

their core tasks. At the same time, there must be opportunity in both financial and policy terms

to cooperate with others in order to meet the requirements of the target group. After all, the

demand for care and assistance is not confined to any one domain. Both housing associations

and healthcare providers should be given budgetary discretion to jointly create, for example, a

meeting area or a local medical centre, perhaps with financial support from the local authority.

Establish a link with care funding, so that there is room to contribute to an integral product

which addresses both the requirements of the target group and the need to reduce healthcare

costs, rather than demanding performance in only one of the three domains.

2. Introduce further separation of accommodation and care costs

Have the providers of intramural care set out clearly which costs are related to accommodation

and which to care relating to chronic health conditions. This does not mean that there should be

two separate invoices from one and the same provider. However, it is important to make

transparent which costs are incurred in the domain of housing, and which in that of healthcare.

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This will also enable people to opt for a different standard of accommodation (be it of higher or

lower quality), which is in the interests of personal freedom of choice. The Council regards this

as the first step in the separation of accommodation and care costs relating to chronic care

indications.

3. Ensure adequate synergy between the WSW and WFZ guarantee funds

There are indications that the Social Housing Guarantee Fund (WSW) and the Guarantee Fund

for the Health Care Sector (WFZ) are starting to focus exclusively on their respective, separate

domains as well. This puts investments in the combination of housing and care at risk. Both

guarantee funds should be requested to facilitate (innovative) investments which straddle the

boundaries between the domains, such as those relating to assisted living, sheltered

accommodation, and ‘accommodation with services’.

5.2 Create incentives for investment and for patient autonomy

4. Encourage stakeholders to invest in pursuing the joint longer-term objectives

The government’s long-term vision on housing, healthcare and welfare should be explicated

by means of a concrete and consistent policy which precludes potential uncertainties for

potential investors.

Encourage investment on the part of homeowners and landlords by means of temporary

(fiscal) measures which make expenditure on ‘future-proofing’ a property more attractive.

Investigate ways in which tenants who invest in modifications can be compensated, e.g. by

means of reduced rents.

Within budgetary planning, seek means which will encourage investment in the housing and

care domains while also stimulating the national economy. This might, for example, entail

removing legislative obstacles, introducing fiscal measures (‘tax breaks’), reducing or

abolishing certain current levies, or implementing subsidy arrangements.

5. Identify and resolve ‘split incentives’

Stakeholders are not inclined to make investments if doing so reduces another party’s costs

rather than their own. For example, a housing association might invest in domotics but it will be

the care provider which gains the greatest benefit in terms of cost reductions. Similarly, a care

provider which invests in cost reduction measures for its patients might see revenues fall as a

result. Creative solutions to such ‘split incentives’ should be sought. For instance: if a health

insurer invests in prevention measures which are successful in reducing health system costs, a

percentage of the amount saved could be paid directly to that insurer.

6. Encourage people to devote timely consideration to their future independent living needs

Homeowners should be encouraged to think about whether their property and its setting will

continue to be suitable should they require (greater) care in future. If not, they will then be

able to take appropriate action. Invite tenants to do likewise so that timely measures can be

taken in consultation with their landlords.

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5.3 Create time and flexibility for ‘smarter’ solutions with lower societal costs

7. Create more time and flexibility within the care real estate transformation process

Greater flexibility is required in the transition and transformation of care sector real estate to

allow appropriate solutions to be found at the local level and to avoid the write-off of valuable

capital assets. The Council suggests an arrangement whereby owners are given two years in

which to formulate and present a ‘transition plan’ which sets out the timeframe for the

transformation itself, in keeping with the specific local conditions and context. This transition

plan should then be assessed and approved by the relevant care agencies and regulators

(including the CSZ where necessary). If the societal costs of the transition can be reduced by

adopting a more gradual process, the opportunity to do so must be allowed. This will overcome

some of the obstacles inherent in the reforms and mitigate their negative impact. Although this

proposal will have implications in terms of the short-term financial objectives, the Council

believes that it is essential to accomplish the structural reform of the sector at lower societal

costs and with less risk of unforeseen costs due to hasty decision-making.

8. Devote attention to short-term solutions for the more vulnerable groups

Over the next five years, an annual average of some ten thousand senior citizens, thirteen

hundred disabled persons, and eight hundred psychiatric patients will become ineligible for

intramural care due to the reforms. The accommodation currently available is not able to meet

their requirements, nor those of the healthcare providers. Alternative short-term solutions must

therefore be found. The patients concerned must be clearly identified at the local level, and

creative solutions must be implemented. Failure to do so will seriously undermine societal

support for the policy reforms. Particular attention must be devoted to the affordability of the

solutions for those with a lower income.

Concluding remarks

The Council concludes that there is significant problem-solving ability available within society,

alongside the capacity to create the synergy required to address the joint objectives of the housing,

care and welfare policy domains. It now falls to stakeholders other than the government itself to

take action. However, the government is uniquely placed to ensure the cohesion and long-term

success of the policy, and indeed has a responsibility to do so. Government must encourage the

stakeholders to commence the transition; it must facilitate the process and must resolve the

conflicts and frictions which the policy amendments will inevitably bring. The transition process will

be enabled by further separating accommodation and care costs and by managing on the basis of

mutual interests and flexibility. It is possible that new questions and issues will arise. The Council is

of course willing to assist in answering those questions. In its work programme for 2014, the Council

for Public Health and Health Care (RVZ) announces the intention of examining in detail the

interrelationship between health, welfare and care on the one hand, and the human environment on

the other. This study will be undertaken in close cooperation with the Council for the Environment

and Infrastructure.

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Yours sincerely,

The Council for the Environment and Infrastructure

Henry M. Meijdam

Chair

Ron Hillebrand

General Secretary

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APPENDIX 1: THE HOUSING, CARE AND WELFARE AGENDAS OF THE

VARIOUS STAKEHOLDERS

Homeowners (owner-occupiers) are to take a proactive approach in considering their desire to live

independently and how this can best be achieved. They will make timely modifications to their

property or take their future (care) requirements into account when relocating to a new home.

Homeowners must acknowledge their own responsibility for funding any necessary modifications,

setting money aside or borrowing against the equity in their property.

Tenants may also be expected to take a proactive approach, devoting timely consideration to

modifications to their home or a move to alternative accommodation. It is essential to explicate

future (care) requirements. There are already many examples of projects in which tenants are

taking a more prominent role in self-management and in the maintenance and improvement of

neighbourhoods. It is hoped that such projects will inspire emulation.

Various collectives and civil initiatives are developing new housing-and-care concepts. Their

projects are promising but in many cases fragile, whereby attention must be devoted to continuity

and imbedding.

Private sector organisations, both the established parties and new entrants to the housing-and-

care sector, are developing new technologies and concepts.

Care providers which own real estate must engage in closer consultation and cooperation with

other stakeholders such as local authorities and housing associations. They must devote due

consideration to the wider social impact of any decision to close locations or change their usage.

They will enter into coalitions (including those with other property owners) with a view to developing

new housing-and-care concepts based on a long-term strategy.

Care providers which do not own real estate must establish a new relationship with the target

group (including more demanding clients and those who avoid seeking assistance), in which the

focus is on the care requirement rather than the intervention. This new relationship may form the

basis of new coalitions with care sector property owners.

Private landlords and investors enjoy opportunities to invest in newbuild and renovation in the

middle segment of the rental market, i.e. properties with a monthly rent of 699 to 900 euros (just

above the threshold for rent subsidy).

Housing associations should (continue to) invest in newbuild property and renovations in order to

create an adequate stock of affordable housing for people with a care requirement. They play an

important role in connecting the domains of housing, care and welfare, and contribute to the

liveability of the human environment.

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Health insurers should (continue to) organise care services in a manner which creates new

connections between the domains of housing, care and welfare, introducing greater emphasis on

prevention and the longer term. For example, the expansion of social networks has been shown to

increase patient autonomy and to decrease reliance on medication.

Banks and financial institutions must introduce new mortgage and savings products with which

care services and home modifications can be financed.

Local authorities are to take the role of process director, but will also act as a consultation partner

and (co-)financier. They must adopt a regional perspective, since not all issues and potential

solutions are confined to the municipal boundaries. They must promote and support initiatives on

the part of informal carers and other volunteers.

Central government must remove obstacles to investment for all stakeholders. It must also ensure

that a cohesive policy is in place within all relevant policy domains, addressing the future of housing,

care, and welfare, both as separate domains and, more especially, in combination. The government

must set out a clear vision of that future which encourages stakeholders – including the public – to

acknowledge their own responsibilities with regard to independent living. Central government will

facilitate the stakeholders in pursuit of the desired future situation. It must also monitor whether the

anticipated increased reliance on volunteers and informal carers remains realistic33.

33 Bijl, R., Boelhouwer, J., Pommer, E., Sonck, N. (2013), De sociale staat van Nederland 2013, The Hague,

Netherlands Institute for Social Research

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APPENDIX 2: STATISTICS

Table 2: Development of intramural care capacity

Year Residential care

places (with no

permanent

medical care)

(x 1,000)

Residential care

places (with

permanent

medical care) (x

1,000)

Total capacity

(x 1,000)

Population aged

80 and over (x

1,000)

Capacity per

person aged

80+

1980 150 46 196 312 0.63

1990 140 52 192 428 0.45

2000 111 59 170 500 0.34

2010 84 74 158 648 0.24

Source: House of Representatives (2012), Scheiden van wonen en zorg (SWZ), technical briefing by the Ministry

of VWS of 7 March 2012, appended to Antwoorden op vragen Leijten over een technische briefing over het

scheiden van wonen en zorg in de AWBZ, Proceedings 2011-2012, No. 2012Z06716

Table 3: Provision of domiciliary care services (AWBZ and WMO), 2012

Client age Domestic assistance

only (WMO)

Medical/nursing care

(AWBZ)

Indication for

medical/nursing care

requirement (AWBZ)

18-65 61,305 98,065 159,680

65-79 129,290 79,240 102,060

80+ 178,775 141,595 140,575

Total 369,370 318,900 402,315

Source: CBS/Statistics Netherlands, Monitor langdurige zorg and Statline

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Table 4: Estimated cumulative number of clients designated ‘living independently for longer’ according to the scenario contained in the Letter to Parliament on the reform of long-term care ZZP 2013 2014 2015 2016 2017 2018 Estimated

overall effect of

independent living

proposals

Total intramural

capacity for sector

VV1 1,100 3,500 5,800 7,000 7,900 7,900 7,900

VV2 3,000 9,000 15,100 18,100 19,900 19,900 19,900

VV3 3,000 9,400 15,600 18,600 18,900 18,900

VV4 (50%) 2,000 6,000 9,000 11,000

Total VV 4,100 15,500 30,300 42,700 52,400 55,700 57,700 150,000

VG1 100 200 400 600 700 900 1,500

VG2 200 700 1,200 1,600 2,100 2,600 5,500

VG3 (50%) 300 900 1,600 2,200 6,600

LG1 + LG3 and ZG1

100 200 300 500 800 1,500

Total GHZ 300 1,000 2,100 3,400 4,900 6,500 15,100 78,000

GGZ1 100 300 400 600 800 800 1,100

GGZ2 400 1,100 1,900 2,600 3,400 3,800 4,000

Total GGZ 500 1,400 2,300 3,200 4,200 4,600 5,100 28,000

Total for all sectors

4,900 17,900 34,700 49,300 61,500 66,800 77,900 255,000

Source: House of Representatives (2013), Hervorming van langdurige ondersteuning en zorg, appendix to Letter to Parliament Hervorming langdurige zorg: naar een waardevolle toekomst, submitted to the House on 25 April 2013, Proceedings 2012-2013, 30 597, No. 296 Key: The ‘indication’ is a coding which represents the medical assessment of a patient’s care requirement. The letters refer to the nature of the disability or infirmity, the figures to its severity. GGZ = Psychiatric condition (often acquired, e.g. depression, addiction etc.)

GHZ = Patients with an intellectual or physical disability or sensory impairment LG = Physical disability VG = Intellectual disability (learning difficulties, usually congenital) VV = Nursing and care (e.g. age-related infirmity) ZG = Sensory impairment (visual and auditory disability) ZZP = Care intensity package

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Table 5: Shortage of suitable accommodation (absolute numbers and percentage of total

stock)

2009

(number of

places/units x

1,000)

2012

(number of

places/units x

1,000)

1 Residential care /

assisted living

40 (29%) 40 (30%)

2 Other accommodation,

by type

Accommodation with services 41 (22%) 46 (26%)

Seniors accommodation – other 43 (18%) 63 (31%)

Accommodation with extensive

modifications

0 (0%) 0 (0%)

Single-storey units Surplus of 36 Surplus of 64

47 (3%) 45 (2%)

Total shortage of

suitable

accommodation (1 + 2)

87 (5%) 84 (4%)

Source: Galen, J. van, Willems, J. & Poulus, C. (2013), Monitor investeren voor de toekomst 2012. Delft: ABF

Research

Table 6: Number of care providers achieving reduction in (acceptable) costs*

Projected

maximum

reduction in

acceptable

costs

0-

2.5%

2.5-

5%

5-

7.5%

7.5-

10%

10-

12.5%

12.5-

15%

15-

17.5%

20-

22.5%

22.5-

25%

>25%

2013 379 273 157 58 17 2

2014 163 127 161 124 75 63 67 50 30 21

* ‘Acceptable costs’ refers to the care provider’s total budget allocated under the provisions of the General

Exceptional Medical Expenses Act (AWBZ) in accordance with current policy regulations.

Source: Dutch Health Care Authority (2012), Advisory report: Scheiden van wonen en zorg in de AWBZ

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APPENDIX 3: BACKGROUND TO THE ADVISORY LETTER

About the Council for the Environment and Infrastructure

The Council for the Environment and Infrastructure (Raad voor de leefomgeving en infrastructuur,

Rli) advises the Dutch government and Parliament on strategic issues concerning the physical

environment and infrastructure. The Council is independent, and offers solicited and unsolicited

advice on long-term issues of strategic importance to the Netherlands. Through its integrated

approach and strategic advice, the Council strives to provide greater depth and breadth to the

political and social debate, and to improve the quality of decision-making processes.

Composition of the Council

Henry Meijdam, Chair

Agnes van Ardenne-van der Hoeven

Marjolein Demmers, MBA

Eelco Dykstra, MD

Léon Frissen

Jan Jaap de Graeff

Prof. Dr Pieter Hooimeijer

Prof. Niels Koeman

Marike van Lier Lels

Prof. Dr Gerrit Meester

Annemieke Nijhof, MBA

Prof. Dr Wouter Vanstiphout

Composition of the advisory committee

Prof. Dr P. Hooimeijer

A.G. Nijhof, MBA, Chair

Prof. Dr A.P.W.P. van Montfort, external expert

Prof. Dr C.J. van Montfort, on behalf of the Scientific Council for Government Policy (WRR)

Composition of the project team

A.M.H. Bruines

Dr L.M. Doeswijk, Project Leader

M.L. van Gameren

Dr V.J.M. Smit

D.K. Wielenga (as of October 2013)

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Experts consulted

Expert meeting of 5 and 6 November 2013

A.P. Berkhout-Pos, MHA, Stichting ActiVite

M. Besselink, MBA, member of the Provincial Executive for Groningen

O. Bremmers, Woonzorg Nederland

Dr F. van Dam, PBL Netherlands Environmental Assessment Agency

C.J. Elemans, ING

E. Fokkema, Atrivé

B. van der Gijp, MRE MMO, Syntrus Achmea Real Estate & Finance Amsterdam

N.L. den Haan, ANBO

Prof. Dr G.R.W. de Kam, University of Groningen

D.M.J.J. Monissen, De Friesland Zorgverzekeraar

R.M. de Prez, alderman for the Municipality of Delft

J.C. van Putten, De Drie Notenboomen / Thomashuizen / Herbergier

I.C. Thepass, Laurens

H.M.H. Windmüller, BrabantWonen/ZorgGoedBrabant

In addition, consultations were held with

F.P. Bassie, Association of Netherlands Municipalities (VNG)

S.M. van Besouw, Municipality of Zoetermeer

E.R. Borggreve, Vestia

Dr C. van Campen, Netherlands Institute for Social Research

Dr K.P. Companje, KHZ

Dr F.B.C. Daalhuizen, PBL Netherlands Environmental Assessment Agency

G. Dolsma, VNO-NCW

Dr I. Doorten, Council for Public Health and Care (RVZ)

Dr C. de Groot, PBL Netherlands Environmental Assessment Agency

E. de Haan, GGZ Nederland

D.J.W. Holtkamp, MSc., Actiz

J.A. Kool, Municipality of Zoetermeer

M.W. de Lint, Council for Public Health and Care (RVZ)

Dr W.J. Meerding, Council for Public Health and Care (RVZ)

F.P. Mostert, Association of Netherlands Municipalities (VNG)

F. Mul, Dutch Association of Healthcare Providers for People with Disabilities (VGN)

R. Prudhomme van Reine, Municipality of The Hague

J.M. Ruyten, Thuis in Welzijn

M. Vegter, Municipality of The Hague

M.A.N. Vroomen, GGZ Nederland

C. Vrouwe, Ons Doel

Y. Witter, Kenniscentrum Wonen-Zorg

31/31

Departmental consultations

M.M. Frequin, Ministry of the Interior and Kingdom Relations

C. van der Burg, Ministry of Health, Welfare and Sport

F.A.H.M. Bonnerman, Ministry of the Interior and Kingdom Relations

S.P.L. Kessels, Ministry of the Interior and Kingdom Relations

C.V. Neevel, Ministry of Health, Welfare and Sport

External reviewers

M. de Langen, Stadgenoot

Prof. Dr P.A.H. van Lieshout, Scientific Council for Government Policy (WRR)

Prof. Dr J. van der Schaar, Rigo Research en Advies

Other

Editorial recommendations: Catherine Gudde, Paradigma producties

Translation: DBF Communicatie, Alphen aan den Rijn

Rli publication 2014/01

January 2014